JASA Housing Management Services for the Aged does not discriminate on the basis of disability status in the admission or access to, or treatment, or employment in its federally assisted programs and activities

December 1, 2021

RE: Israel Senior Citizen I & II – LOTTERY APPLICATION

Dear applicant,

Enclosed is an application for Israel Senior Citizen I & II, with 512 apartments for low-income elderly near the beach. The property is located at 155 Beach 19th Street and 1925 Seagirt Blvd in Far

Rockaway, NY. This is a HUD subsidized property with Section 8 subsidies available to most residents.

Tenant Rent: Tenant rent is based on 30% of the tenant’s adjusted gross monthly income.

Eligibility Requirement: One or two-person household. Applicant head of household must be at least

62 years old. All household members must meet project and program eligibility.

Family composition requirements and maximum annual household income are:

Apartment Size Family Composition Maximum Annual Household Income

Studio 1 to 2 persons One (1) Person: $41,800* Two (2) Persons: $47,750*

One Bedroom 1 to 2 persons One (1) Person: $41,800* Two (2) Persons: $47,750*

*Income level are subject to change based on HUD guidelines

Deadline: Application must be received no later than December 31, 2021.

INSTRUCTIONS:

1. SUBMIT ONLY ONE APPLICATION PER HOUSEHOLD. The application will be rejected if more

than one application is received per lottery for any member of a household or a single person appears in on more than one application.

2. Complete applications must be postmarked by FIRST-CLASS mail, mailed in a #10 or #9 envelope (no larger than 9 ½ inches by 4 ¼ inches) to the address listed on the application. Application sent

certified, registered, priority, or express mail, or if they are received after the above deadline will be

not be eligible for the lottery if submitted. 3. APPLICATIONS ARE SELECTED RANDOMLY THROUGH A LOTTERY PROCESS. Israel Senior

Citizen I & II will only randomly select 750 applications for processing. 4. You must complete all information, as well as sign and date the application in order for your

application to be reviewed if it is selected for further processing. 5. The application should be completed very carefully. Incomplete information for the number and

names of household members applying to live in the unit, or their incomes, will result in

disqualification. 6. ONLY THE APPLICATION should be submitted at this time. If your application is selected for

further processing, additional information will be requested at that time. Mail completed application

to:

Israel Senior Housing I and II P.O. Box 6249

Hoboken, NJ 07030

7. No payment should be given to anyone in connection with the preparation or filing of this application.

You have the right to request a reasonable accommodation due to a disability to facilitate completing a

housing application, you may call (212) 273-5359 or TTY Relay 711 for hearing the impaired.

JASA Housing Management Services for the Aged does not discriminate on the basis of disability status in the admission or access to, or treatment, or employment in its federally assisted programs and activities

FOR OFFICIAL USE ONLY: Date and Time Received ______________

Applicant No. ______________

Israel Senior Housing I & II – Lottery Application The head of household must be at least 62 years of age at the time of application.

Application are FREE. No money should be given to anyone in connection with the preparation, filing, or processing of this application.

MAIL TO: Israel Senior Housing I and II

P.O. Box 6249 Hoboken, NJ 07030

APPLICATION MUST BE RECEIVED BY DECEMBER 31, 2021.

You have the right to request a reasonable accommodation due to a disability to facilitate completing this housing application, you may call (212) 273-5359 or TTY Relay 711.

*If you mail your application to any other address, it will not be considered and your application will be shredded. SUBMIT ONLY ONE APPLICATION PER HOUSEHOLD. Only ONE application must be submitted for each applying household, and no individual can be represented as a member of more than one household. MULTIPLE APPLICATIONS. If selected in the lottery, duplicate applications and applicants that include a household member who also appears on another application will be rejected. The head of household must fill in all information. If an item is not applicable, write “N/A”. Sign the last page. Each application selected will be logged, and as the respective application numbers are reached, applicant will be called for an interview and additional information will be requested at that time. Incomplete application WILL NOT be accepted. Applicant Name (First and Last Name): _______________________________________________________

Street Address: ____________________________________________________________________________

City, State and Zip Code: _____________________________________________________________________

Telephone Number: __________________________ E-mail: ________________________________________

HOUSEHOLD INFORMATION

List all persons who will occupy the apartment, including yourself and persons to join the household.

Household Member Relationship to

Head of Household Date of Birth

Are you a US Citizen?

Social Security (Last 4 digits)

SELF

Yes No

Yes No

Yes No

*If your application is selected during the lottery, and the above Household Information is incomplete, your application will not be accepted.

Page 2 of 4

INCOME INFORMATION

List all other income source for ALL HOUSEHOLD MEMBERS (including yourself) WHO WILL BE LIVING WITH YOU, including: Welfare (including housing allowance); AFDC; Social Security; SSI; Pension; Worker's Compensation; Unemployment Compensation; Interest Income; Babysitting; Care-Taking; Alimony; Child Support; Annuities; Dividends; Income from Rental Property; Armed Forces Reserves; Scholarships and/or Grants; Gift Income; and/or any Other Income.

Household Member Type of Income

Gross Income (Before any deductions or taxes)

$ per Month Yearly

$ per Month Yearly

$ per Month Yearly

CURRENT HOUSING INFORMATION

Landlord Name: _____________________________________________________________________

Landlord Address: ____________________________________________________________________

Landlord Phone Number: ______________________________________________________________

Are you presently receiving a Section 8 Housing Voucher or Other Subsidy/Certificate?

No Yes – HPD/NYCHA Section 8 Voucher Yes – Other Rental Subsidy/Certification

PROGRAM INFORMATION

1. How did you hear about our development? _______________________________________________

2. Are there any special accommodations that the household will required (i.e. grab bars, live-in aide, etc.)? ___________________________________________________________________________________

3. Were you or any household member ever convicted of a felony or misdemeanor? No Yes

If yes, who? _________________________________________________________________

4. Has anyone in your household been convicted of violating any drug-related laws? No Yes

If yes, who? _______________________________________________________________

5. Is any member of your household subject to a lifetime sex offender registration requirement? No Yes

If yes, who? ______________________________________________________________

6. List all the states in which you and all household member have resided (now or in the past): _______________________________________________________________________________________

Page 3 of 4

WARNING: MISLEADING WILLFUL FALSE STATEMENT, MISREPRESENTATION, OR INCOMPLETE INFORMATION IN THIS APPLICATION WILL BE GROUNDS FOR REJECTION OF THIS APPLICATION.

I certify that the above information is correct to the best of my knowledge. I understand that, if this application is selected in the lottery, I will be required to submit additional information. I will be required to provide documentation for the purpose of determining eligibility. Management will conduct a background check of all adult household members listed in this application as part of the application process, and I authorize this background check. ___________________________________________________ ___________________________ Signature of Head of Household Date ___________________________________________________ ____________________________ Signature of co-head or Household or other Adult Member Date ___________________________________________________ ____________________________ Signature of co-head or Household or other Adult Member Date

Feel free to include additional pages if more space is needed to answer application question

DEMOGRAPHIC DATA (Your answers pertaining to demographic data is voluntary) The following information is helpful to determine program utilization and for statistical purposes only.

This information will not affect the processing of this application.

Ethnicity: Hispanic or Latino? Yes No Race: (Check all that apply)

White Black or African American Asian

American Indian or Alaskan Native Native Hawaiian & Other Pacific Islander

Page 4 of 4

OMB Control # 2502-0581 Exp. (02/28/2019)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,

the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other

organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any

issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,

remove, or change the information you provide on this form at any time. You are not required to provide this contact information,

but if you choose to do so, please include the relevant information on this form.

Applicant Name:

Mailing Address:

Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No: Cell Phone No:

E-Mail Address (if applicable):

Relationship to Applicant:

Reason for Contact: (Check all that apply)

Emergency

Unable to contact you

Termination of rental assistance

Late payment of rent

Assist with Recertification Process

Change in lease terms

Change in house rules

Other: __________________________

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues

arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the

issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the

applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)

requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or

organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity

requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing

programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age

discrimination under the Age Discrimination Act of 1975.

Check this box if you choose not to provide the contact information.

Signature of Applicant Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520).

The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and

completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing

providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for

occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The

objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special

care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and

maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and

management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond

to, a collection of information, unless the collection displays a currently valid OMB control number.

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be

used by HUD to protect disbursement data from fraudulent actions.

Form HUD- 92006 (05/09)